Is it ADHD or a Sleep Problem?

Attention span, concentration, and distraction issues are common problems seen in children and teens at mental health and primary care medical clinics. The problems typically are noticed as school work and school structure become a major issue of focus. In elementary aged children, child expectations involve ability to follow class expectation, general participation, and skill in following school work with heavy parent/teacher involvement. Behavioral concerns for children with suspected ADHD (Attention Span/Hyperactivity Disorder) often include trouble with attention, distraction, restless behavior, and problems with follow-through. These children are often restless, impulsive, fidgety, and can have poor ability to demonstrate patience.

In pre-teens and teens, school work typically becomes more challenging; it requires increased self-direction, less supervision during school assignments, increased need for self-motivation, and increasing need to combine complex information and thinking when solving problems. In short, the older the child, the more independent and harder their brains must work.

During an ADHD assessment, potential for sleep problems need to be evaluated. If a sleep disorder exists, accurate assessment, diagnosis, and treatment of ADHD symptoms may be challenging at best or misguided at worst until sleep issues are addressed. Sleep deprivation resulting from insufficient sleep, poor sleep quality, or airway issues (apnea) have long been known to create problems with cognitive abilities. Chronic poor sleep can result in:

· Problems with sustained concentration

· Problems with memory retention

· Problems with memory consolidation

· Problems with memory recall

· Poor motivation

· Low energy

· Distraction

· Restlessness

· Trouble with organization of thought (i.e. planning)

So… how can you tell the difference between symptoms of ADHD and sleep deprivation? Sleep studies show that children with ADHD tend to move their limbs more during sleep, sleep less, may take longer to fall asleep, experience shorter sleep times; and have more frequent daytime sleepiness than children who do not have ADHD. Further, children with ADHD who are not typically tired during the day often show problems of inattention and concentration as well as impulsiveness despite adequate sleep. Thus, it is important to fully evaluate the sleep patterns of your child. For instance, how long does it take them to fall asleep; do they wake at night; and are they waking too early? A good rule of thumb for total sleep needs are as follows:

· Infants need 9-10 hours at night and 3-4 hours during the day

· Toddlers need between 11 and 13 hours combined during night and day on average

· Preschoolers need between 9-10 hours during the night plus naps (until the child reaches 4-5)

· Elementary school aged kids need about 9-10 hours on average

· Adolescents need about 9 hours on average

· Adults need about 8 hours on average

Determine if your child is tired (low on overall energy) during the day or sleepy (has a hard time keeping their eyes open or head off the desk). Children with moderate sleep deprivation tend to show fatigue by being “wound up,” silly, irritable, distractible, and poorly focused. With increasing sleep problems, they become low in energy, poorly motivated, slow moving, and unable to focus on tasks. Problems with insufficient sleep require intervention such as improvements in sleep amount and quality. Specific interventions may be needed to improve stubborn problems with overall sleep length and quality. Sleep conditions not related to breathing issues such as apnea can be typically corrected by working with a behavioral sleep psychologist.

Does your child snore, hold their breath, or gasp for air at night while sleeping? Are they tired or sleepy despite getting enough sleep at night? If so, they may have apnea, a brief, repeating pause in breathing during their sleep. The best way to determine if apnea is a problem is a consultation with your primary care provider who may request sleep study or assessment by an ENT (Ear Nose and Throat) specialist to screen the child.

It is, of course, possible that sleep issues AND problems with ADHD exist together. It is only with a competent, thorough assessment of both factors that an accurate assessment and diagnosis of ADHD can be made.